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Use of Antipsychotic Drugs in Dementia Josepha A. Cheong, MD University of Florida Departments of Psychiatry and Neurology Chief, Division of Geriatric Psychiatry What are common behavioral disturbances? • Agitation – Physical – Verbal – Resistiveness • Mood – Depression – Anxiety What are common behavioral disturbances? • Psychosis – Disruption in the ability to differentiate real from unreal – Hallucinations – Illusions • “Sundowning” Assessment • Rule out any environmental disturbance – change in home setting – change in the staff/family members – death of a pet Assessment • R/o any possible medical illness – urinary tract infection – dehydration Assessment • R/o drug-drug interactions or drug intolerance Assessment • When does the behavior occur – constant regardless of stimuli – specific time of day – with caregiving activity Assessment • Endocrine • Iatrogenic - consider non-prescription medications • Injury • Intoxication Treatment • Behavioral Intervention • Antidepressant medications • Antipsychotic medications What is Psychosis? • The state in which a person is unable to differentiate “real” from “unreal” • Misperception of stimulus • Hallucinations • Illusions • Delusions • Agitation Antipsychotic Medications (doses adjusted for the geriatric age group) • • • • • haloperidol (Haldol) .5 - 2.0mg risperidone (Risperdal) .5 - 6.0mg olanzapine (Zyprexa) 2.5 - 10.0mg ziprasidone (Geodon) 20-40mg quetiapine (Seroquel) 25mg - 300mg*** General Guidelines • Monitor very carefully for side effects • Monitor for benefit • Consider decreasing the dose if symptoms improve • Monitor for increased sedation and adjust the time of dosing FDA Warning – April 2005 Deaths with Antipsychotics in Elderly Patients with Behavioral Disturbances • 15 out of 17 placebo-controlled trials showed numerical increases in mortality in the drug-treated group compared to the placebo-treated patients – N = 5106 involving Risperidone (7 trials), Olanzapine (5 trials), Aripiprazole (3 trials) and Quetiapine (2 trials) – ~1.6-1.7 fold increase in mortality in active treatment over placebo • Specific causes of these deaths: – Heart related events (e.g., heart failure, sudden death) or infections (mostly pneumonia) FDA Public Health Advisory (4/05) Adverse Effects with Atypical Antipsychotics • Dyslipidemia • Glucose metabolism change • Possibility of sudden death secondary to heart failure, cardiac event or infection Adverse Effects with Atypical Antipsychotics Clinical Considerations: • What are the risk factors of this particular patient? (history of cardiac problems, diabetes, and or hypertension?) • What alternative treatments have been tried – what was the response? Adverse Effects with Atypical Antipsychotics Clinical Considerations: • What benefits does the patient receive from the particular antipsychotic vs. how is the patient’s behavior without or prior to the initiation of the medication? • Have other intervention methods or medications been tried already? Adverse Effects with Atypical Antipsychotics Recommendations for management: • Document need • Discussion of alternate treatments • Patient/Family consent • Use lowest possible doses – monitor for side effects Rules of Thumb • Not everything needs to be treated with a medication Rules of Thumb • Not everything needs to be treated with a medication • Start at a low dose and titrate slowly Rules of Thumb • Not everything needs to be treated with a medication • Start at a low dose and titrate slowly • Not everything needs to be treated with a medication Baker Act - 52/32 • 52 - involuntary evaluation • 32 - involuntary committment Referral Shands at UF Inpatient Geriatric Psychiatry Unit Intake Coordinator 352-265-5411 GO GATORS!